Opportunistic infections

1. Pneumocystis carinii pneumonia is rarely encountered in patients receiving prophylactic therapy. Indications for prophylaxis are a CD4+ count below 200 cells/^L, HIV-related thrush, or unexplained fever for 2 or more weeks regardless of CD4+ count. Anyone with a past history of PCP should continue suppressive therapy indefinitely because of the high risk of relapse.

2. Toxoplasmosis risk increases as the CD4+ count approaches 100 cells/^L, and patients who are seropositive for IgG antibody to toxoplasma should begin preventive therapy when the count nears this level. Patients who have been treated for toxoplasmosis require lifelong suppressive therapy.

Pathogen

Indication for 1 First-choice drug prophylaxis 1

Selected alternative drugs

Prophylaxis Strongly Recommended

Pneumocystis carinii

CD4+ count <200 cells/^L or unexplained fever for >2 wk or oropharyn-geal candidiasis

TMP-SMX (Bactrim, Septra), 1 DS tablet PO daily

Dapsone, 100 mg PO daily, or aerosolized pentamidine (NebuPent), 300 mg monthly

Mycobacterium tuberculosis

Tuberculin skin test reaction of >5 mm or prior positive test without treatment or exposure to active tuberculosis

Isoniazid, 300 mg PO, plus pyrid-oxine, 50 mg PO daily for 12 mo

Rifampin, 600 mg PO daily for 12 mo

Toxoplasma gondii

IgG antibody to T gondii and CD4+ count <100 cells/^L

TMP-SMX, 1 DS tablet PO daily

Dapsone, 50 mg PO daily, plus pyrimethamine (Daraprim), 50 mg Po weekly, plus leucovorin (Wel-lcovorin), 25 mg PO weekly

Mycobacterium avium complex

CD4+ <50 cells/uL

Clarithromycin (Biaxin), 500 mg Po bid, or azithromycin (Zithromax), 1,200 mg PO weekly

Rifabutin

(Mycobutin), 300 mg PO daily

Streptococcus pneumoniae

All patients

Pneumococcal vaccine (Pneumo-vax 23, Pnu-Im-mune 23), 0.5 mL IM once

None

Consideration of Prophylaxis Recommended

Hepatitis B virus

All seronegative patients

Hepatitis B vaccine (Engerix-B, 20 pg IM x S, or Recombivax HB, 10 ^g IM x S)

None

Influenza virus

All patients, annually before influenza season

0.5 mL IM

Rimantadine (Flu-madine), 100 mg PO bid, or amantadine (Symadine, Symmetrel), 100 mg PO bid

C. Tuberculosis. Patients who have HIV infection and positive results on tuberculin skin tests have a 2-10% per year risk of reactivation. If active tuberculosis has been excluded, prophylaxis should be prescribed to

HIV-infected patients who have a tuberculin skin test reaction of 5 mm or more, who have a history of a positive tuberculin skin test reaction but were never treated, or who have had close contact with someone with active tuberculosis.

D. Mycobacterium avium complex infection. Prophylactic therapy is recommended for patients whose CD4+ counts are less than 50 cells/^L. Azithromycin (Zithromax), 1,200 mg (2 tabs) weekly by mouth is recommended.

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